Anda di halaman 1dari 72

STROKE

Presence Regional EMS System


September 2013

Grandpa had a stroke

Not too long ago this statement meant death or


disastrous disability for patients and families.

In the 21st century medical


science has progressed in
the understanding of STROKE,
prevention and treatment

How

big is the problem of


STROKE?

Magnitude of the Problem


795,000 Americans annually suffer a
STROKE
25% die
#3 killer of Americans
25% of women have strokes
before age 65
#1 cause of long term disability

Stroke in the US
One case of stroke every 45 seconds
Results in devastating disability

16% institutionalized in nursing homes


31% assistance with Activities of Daily Living
(bathing, dressing eating)
20% assistance with walking
30% depressed
Annual cost of $68 billion

New Advancements

The FDA has approved the same clot busting


drugs (tPA thrombolytic) used in heart attacks to
be used in brain attacks stroke.

For a variety of reasons, only 2% of stroke


victims are treated with thrombolytic medication

Aggressive treatment begins with assessment


and intervention at point of patient contact

Before STROKE can be


managed

Learn more about what strokes are and


how they happen.

A very selfish organ


The brain requires
20 % of
the total blood
pumped
by the heart.
No storage
in the brain for
either fuel or oxygen
Requires constant
supply of oxygen and glucose.

Blood Supply to the Brain

Carotid arteries anterior neck

Large
Frequently congested
with plaque
Can be cleaned out surgically

Vertebral arteries

Pass through cervical vertebrae


Well protected
Not accessible for
surgical cleaning

Circle of Willis
Both blood supplies (carotid and vertebral) join
on the under surface of the brain.
Fail-safe mechanism
in case of a blockage
somewhere in
circulation
BUT some hard corners in
circle where debris can get
caught and site of most
cerebral aneurysms

What can go wrong???

Disruption of blood flow to the brain


Plaque build up of cholesterol in interior of
blood vessel
Foreign debris
blood clot
bubble of fluid
air
Broken vessel

Ischemic STROKE

Blockage of blood flow to brain


Progressive Thrombus -- growing

Plaque deposit similar to process in heart with


coronary artery disease

Cerebral Emboli --Clot from somewhere else -floating debris

Blood clot
Air bubble
Bubble of amniotic fluid
Bone marrow from
a fracture

Hemorrhagic STROKE

Aneurysm weakened area in artery


Congenital
Younger population younger than 40 years
Complain of worst headache in my life

Spontaneous Hypertensive Bleed

Due to BP > 200/100

Malformed Artery

50% younger than 30 years

Transient Ischemic Attack

One Free Spin


Looks like a stroke but,symptoms improve in
1-24 hours
Temporary disruption of blood flow to the
brain Like Unstable Angina of the brain
Warning sign (15% of strokes have TIA first)
Mimicked by low blood sugar (> blood sugar
signs and symptoms go away)
1 in 20 patients will have a true stroke in 3
months

Can STROKES be prevented?

Modifiable risk factors


High BP
Cigarette smoking
Alcohol intake
Uncontrolled Heart disease
Atrial fibrillation
(creates mini clots)
Uncontrolled Diabetes
Carotid congestion

High blood cholesterol


Sedentary lifestyle
Obesity
Seasons spring and fall
Stress

Risk Factors Unable to Control

Age
Gender

Race

more women than men

African American high risk

Prior strokes
Heredity
Sickle Cell Disease

Causes clot formation and


strokes even in children

Signs and Symptoms of


STROKE

Hemorrhagic

Sudden and dramatic


Violent explosive headache

Visual disturbance

Flashing lights, aura

Nausea and vomiting


Neck and back pain

worst headache of my life

Due to blood in sub-arachnoid space

Sensitivity to light
Weakness on one side
Can present like a migraine headache

Signs and Symptoms of


STROKE

Ischemic Stroke
Harder to detect
Weakness in one side
Facial drooping
Numbness and tingling
Language disturbance
Visual disturbance

Left Brain Stroke


Right side paralysis
Speech and language disturbance
Behavioral changes
Swallowing problems

Right Brain Damage


Left side paralysis
Spatial perception

Where your limbs


are in relation to the room

Coordination problems
Perception

Recognition of familiar
objects

Primary Stroke Care

180 minute window of time

Time is tissue
The longer the brain is without
oxygen and glucose the more
brain cells die

Goal is to restore blood flow as


soon as possible

Treatment is a system beginning with early


recognition and continuing through rehabilitation

Goals of Primary STROKE Care


Rapid Recognition of STROKE Symptoms
Rapid access in to the medical system
Assessment
Treatment

Seven Ds of STROKE Care


Detection of STROKE symptoms
Dispatch of EMS/ MET Team
Delivery to a facility prepared to manage STROKE
Door to treatment rapid diagnosis and decision

making

Data CT Scan
Decision Ischemic or Hemorrhagic, does the patient

meet the criteria to receive thrombolytic drugs

Drug thrombolytics when appropriate

EMS Has a Critical Role


Educate your community
At first signs of a possible STROKE call
EMS

Many families wait to see if the patient gets


better
Take patient to the hospital by car

Dont guess call EMS!!

Use a FAST STROKE


Assessment

Modification of Cincinnati Pre-Hospital


Stroke Screen

Face

Arm
Speech

Time

of onset

FACE

Look for Facial Droop


Have the patient smile or show his/her teeth
NORMAL Both sides of the
face move equally
ABNORMAL One side of
the patients face droops
or does not move

ARMS
Motor Weakness: Look for arm drift by asking
the patient to close eyes and lift arms
NORMAL- arms remain
extended equally or drift
downward equally
ABNORMAL One arm
drifts down compared
to the other

Problem with gripping hands


Many elderly have arthritis in hands
Hurts to grip hands
May mimic weakness

SPEECH

Ask the patient to say You cant teach an


old dog new tricks

Lots of ts, ks and cs

NORMAL Phrase repeated clearly and


plainly
ABNORMAL Words slurred, abnormal or
unable to speak

Abnormal Speech

Slurring of speech
Unable to think of words
Inappropriate words
Expressive aphasia unable to speak words

Area of brain where words are created is damaged

Receptive aphasia unable to understand


words

Area where words are interpreted is damaged

TIME OF ONSET

The window of opportunity to effectively


treat STROKE is 3 hours (180 minutes)

May be extended to 4 hours in some cases

Need to know last known well.


Difficult when

Patient lives alone


Woke up with symptoms

180 minutes
Dont think of as 3 hours, but 180 minutes
Time gets eaten up fast
Short scene time
Take transport time into consideration

Assessing the Stroke Patient

Initial Assessment
General Impression
Airway Airway Airway!!
High-flow O2
Circulation
HIGH PRIORITY TRANSPORT

Focused history and physical exam

Perform thorough neurologic exam.


FAST

Stroke Screen
History of

Seizures
Headache
Nausea/vomiting
Neck pain

Obtain baseline set of vitals


Recheck

Vital Signs frequently

Priorities of care

Conduct general assessment

Trauma recent or within last month

Cardiovascular on heart medications

Does the patient have atrial fibrillation


Does the patient take blood thinners

Pulse oximetry > 94%


Blood sugar treat if able

Recent seizure
Could be a subdural hematoma

Low blood sugars mimic a stroke

Pupils

Position

Protect potentially paralyzed parts

STROKE Check List

Securing A B Cs
Stroke identification
Use of FAST Screen
EKG monitoring if able
Oxygen saturation of > 94%
Management of blood glucose
IV access (ILS/ALS)
Blood specimens obtained (ILS/ALS)
Head of Bed elevated 15 degrees
Early communication with Physician
Urgent transport to CT Scan

Non Contrast CT of Head


Want a normal CT

Acute Hemorrhagic Stroke


Blood shows up white

Sub Arachnoid Bleed


Blood in meninges due to
aneurysm

Could this be anything other


than a STROKE?

Transient Ischemic Attack

Hypoglycemia

Race Against Time

Goals of STROKE Care 2013


Standardized assessments, vocabulary,
protocols and goals
Door to treatment (with thrombolytics)
goal is 60 minutes
Early identification of candidates
Direct transport to CT scan

NINDS** Recommended Goals

Door to doctor
Door to CT completion
Door to CT read
Door to treatment
Access to neurological expertise*
Access to neuro-surgical expertise*
Admit to monitored bed

10 minutes
25 minutes
45 minutes
60 minutes
15 minutes
120 minutes
180 minutes

* by phone or in person
** National Institute of Neurological Diseases and Stroke

Case Study 1: 6:30 pm

You are called by a family member to


assess a patient who is not acting right.

What could be the problem?

Keep an eye on the time


you have 180 minutes

What could be the problem?


Seizure
Code
Myocardial infarction
Diabetic reaction
Medication reaction
Anxiety attack
STROKE

6:35 pm

Upon arrival, you find the patient, Mrs.


Short, sitting in bed. She is confused, but
responds to verbal stimuli.

What assessments do you need?

ABC/FAST
Airway and ventilations are adequate
Regular pulse and good perfusion
Speech is garbled
Unable to move her right arm and leg
Denies chest pain.
BP 195/105, pulse 90, respirations 18

The patients daughter reports that her mother


felt fine a few minutes ago when suddenly her
arm felt funny. She did not lose consciousness
and did not have a seizure.

The woman did not complain of a headache,


and has no history of seizures, diabetes, chest
pain or palpitations.

6:43 pm

This patient, Mrs. Short, is 65 years old.


She has left sided facial drooping and right
arm and leg weakness. She can move the
right arm and leg slightly, but with great
difficulty. Her speech is slurred. All of
these signs and symptoms are new in the
last 10 minutes.

FAST

How does Mrs. Short fare on the FAST


Screen?
Face
Arm
Speech
Time

Case 1 cont
Face -- left sided facial drooping
Arm right arm and leg weakness
Speech speech is slurred
Time last known well within 20 minutes

HIGH PRIORITY
Determine precise time of onset of signs
and symptoms.
If thrombolytic therapy is to be considered,
its infusion must begin within 3 hours of
the onset of symptoms.

Does Mrs. Short meet the criteria so far to


be on the Primary STROKE Care track to
receive thrombolytics (tPA)?

YES, Proceed with Stroke protocol

Case Study 2: 0635 Hours


70 year-old woman, Mrs. Black
Awake with slight weakness and tingling
in her left side.
Speech is hesitant and slightly slurred
No facial drooping
Good eye contact

Case 2 cont.
Symptoms began 0615 per patient
Speech was fine before that
Blood sugar 50 mg/dl
No emesis or seizure
BP 150/90, Pulse 80, Respirations 16
O2 sat 92%

FAST

How does Mrs. Black fare


on the FAST Screen?
Face
Arm
Speech
Time

Case 2 cont
Face -- no drooping
Arm slight weakness and tingling
Speech -- Speech is hesitant and slightly
slurred
Time known well -- 20 minutes ago

Case 2
BUT blood sugar is low!
Treat the blood sugar and reassess the
need for additional treatment
High priority transport to
a CT for acute STROKE

Case Study 3
Ambulance call at 1400 hours
80 year-old man, Mr. Schmidt
Daughter found him 15 minutes ago
Unknown down time
Awake
Drooping left side of face
No movement of right arm and leg
Speech too slurred to understand

Case 3 cont.
Blood sugar 200 mg/dl
No evidence of seizure or emesis
BP 180/100, pulse 72, respirations 15

FAST

How does Mr. Schmidt fare


on the FAST Screen?
Face
Arm
Speech
Time

Case 3 cont
Face --Drooping left side of face
Arm No movement of right arm and leg
Speech Speech too slurred to
understand
Time known well unknown, daughter
found him 15 minutes ago, but she had not
had contact with him since yesterday

Case 3

Time window has closed. Not a candidate


for thrombolytic treatment. Transport to
ED for acute care.

Quiz

What are the 2 general types of stroke?

What condition is equivalent to angina of the


brain?

1.
2.

3.

What are 3 risk factors for stroke that can be


modified?

4.
5.
6.

What are 2 risk factors for stroke that cannot be


modified?

7.
8.

What are you measuring in a FAST Stroke


Screen?

9.
10.
11.
12.

In the 21st century, some patients suffering


from STROKE can be treated using what
type of medication?

13.

What is the time deadline that must be met


in order to use the aggressive medication
in the question above?

14.

Answers

1. Hemorrhagic stroke
2. Ischemic stroke
3. TIA (transient ischemic attack)
4. 6. High BP

Cigarette smoking
Sedentary lifestyle
Obesity
Seasons
Stress
Alcohol intake

High blood cholesterol


Carotid Congestion
Uncontrolled diabetes
Atrial fibrillation
Uncontrolled heart disease

7-8

Age
Gender
Race

9.

prior strokes
heredity
Sickle cell disease

Face
10. Arm
11. Speech
12. Last known well

13. Clot busting drugs, thrombolytics, tPA


14. 3 hours (180 minutes)

Anda mungkin juga menyukai